fentanyl with or without bupivacaine in reducing pain in patients undergoing video-assisted chest surgery

Conditions: Pain; Perioperative/Postoperative Complications

Summary: rationale: patient-controlled analgesia using fentanyl and bupivacaine may lessen pain caused by video-assisted chest surgery. giving bupivacaine in different ways may give better pain relief. purpose: thisrandomized clinical trial is comparing three different ways to give bupivacaine together with fentanyl to see how well they work in reducing pain after video-assisted chest surgery.

objectives: primary * to compare the efficacy of intravenous, patient-controlled, narcotic pain management alone to the efficacy of intermittent bolus injection of bupivacaine hydrochloride via an intrapleural catheter in patients who have successfully undergone video-assisted thoracic surgery (vats). secondary * to compare the efficacy of intermittent bolus administration of bupivacaine hydrochloride to the efficacy of continuous bupivacaine hydrochloride administration via an intrapleural catheter in patients who have successfully undergone vats. * to compare visual analog scale pain scores at all measurement times. * to compare patient satisfaction scores for each method of pain control. * to compare rates of conversion from bolus delivery to intravenous narcotic delivery. * to compare rates of conversion from continuous intrapleural infusion to bolus delivery or intravenous narcotic delivery alone. * to compare the total amount of narcotics used between bolus intrapleural delivery and continuous intrapleural infusion. outline: patients are randomized to 1 of 3 treatment arms. * arm i: patients receive intravenous patient-controlled analgesia (iv-pca) fentanyl citrate beginning once the patient is awake and alert after surgery and continuing for 24 hours. * arm ii: patients receive intermittent intrapleural bolus bupivacaine hydrochloride immediately after surgery and then at 6, 12, 18, and 24 hours after surgery and iv-pca fentanyl citrate as in arm i. * arm iii: patients receive a continuous infusion of intrapleural bupivacaine hydrochloride beginning immediately after surgery and continuing for 24 hours and iv-pca fentanyl citrate as in arm i. in all arms, visual analog scale measurements are taken at baseline and 6, 12, 18, and 24 hours post-surgery. after 24 hours, a 5-point likert scale survey is administered to assess overall patient satisfaction with pain control in the 24-hour postoperative period.

Eligibility criteria:
disease characteristics: * candidate for video-assisted thoracic surgery (vats) and unlikely to require conversion to open thoracotomy as determined by physician * able to satisfactorily complete a visual analog scale (vas) measurement * patients who are too sedated postoperatively or who are unable to properly mark a vas scale due to other factors (poor eyesight, lack of manual dexterity, or lack of comprehension of the test) are ineligible patient characteristics: * no allergy to bupivacaine hydrochloride or fentanyl citrate * no known renal or liver disease (i.e., hepatic insufficiency or cirrhosis) that would affect metabolism of drugs used in this study * not pregnant or nursing * negative pregnancy test * no thoracic infection within the past 3 months * weight ≥ 55 kg * alt and ast \< 10% of upper limit of normal * serum creatinine \< 1.5 mg/dl * bun \< 40 mg/dl prior concurrent therapy: * no concurrent narcotics for pain management * no concurrent amiodarone, barbiturate anesthetics or other cns depressants, diazepam, droperidol, nitrous oxide, or protease inhibitors

Keywords: pain perioperative/postoperative complications